Doctors Explain How That Viral Image of a Lung-Shaped Blood Clot Happened


Detached medical terminology almost makes the situation bearable: “During an extreme bout of coughing, the patient spontaneously expectorated an intact cast of the right bronchial tree.”

Translate to layman’s terms, and suddenly life is a gory horror movie: some poor patient hacked up a bloody perfect replica of the right side of their lungs.

In an Instagram post, The New England Journal of Medicine released a photo featuring the 6-inch-wide blood clot in the shape of a patient’s right bronchial tree on November 23. The medical journal, which has a reputation for publicizing photos of unique medical cases, also shared the image in a now-viral tweet on December 3. The creator of the cast, a 36-year-old man admitted to the ICU for heart failure, died a week after the photo was taken, due to medical complications.

right bronchial tree.
Some say this cast of the right bronchial tree looks like red decorative coral, or a holiday tree decorated with red lights. Your pick.

The NEJM regularly drops medical images not safe for the squeamish, but this blood clot took the Internet’s breath away. In addition to amassing many a shocked gif, the photo collected 2,244 retweets and over 4,200 likes as of this article’s publication.

This Gross Event Has Happened Before

Unfortunately — here’s your gross content warning — this is not anywhere near the first time patients have coughed up (casts of) their lungs. Twitter user @chifle12 reported a similar gross artifact expelled from a 6-year-old, made of lymphatic fluid. Patients suffering from asthma can also form casts from mucus that hardens in airways.

And there’s more. Suffering from laryngeal diphtheria, a 34-year old woman produced a similar cast of her trachea in 1926. More recently, a 25-year-old pregnant woman hacked up yet another bronchi-shaped blood clot in 2005. In that case, the patient recovered and delivered a healthy baby.

What makes this most recent instance special is its material and its unprecedented size. Not only is blood typically less hardy than other bodily materials that can achieve this gross shape, but the patient’s 6-inch-wide sample emerged perfectly intact. When unfurled, Georg Wieselthaler, M.D., a transplant and pulmonary surgeon at the University of Florida at San Francisco, identified the origin of the massive clot immediately.

“We were astonished,” Wieselthaler told The Atlantic. Based on the way the clot faithfully traced the branches of the patient’s airway, he and his team quickly identified it as his right bronchial tree. “It’s a curiosity you can’t imagine — I mean, this is very, very, very rare.”

How Did This Gross Blood Form?

Doctors have a couple ideas to explain this massive medical anomaly.

When the human body is running properly, bronchi are pathways for the oxygen you breathe in and the carbon dioxide you expel. Like an upside down tree, the web of branches spindles out into smaller bronchioles that are closed at the tips by alveoli, where your bloodstream carries red blood cells to pick up and drop off oxygen and carbon dioxide.

In the case of the unfortunate patient, there was much more than air in his bronchi. When he was admitted to the ICU, doctors hooked him to a ventricular assist device, called an Impella, that helps maintain blood flow. But the turbulence of the world’s smallest heart pumps can cause clots, so the doctors countered the effect by giving the man an anticoagulant to thin his blood.

The anticoagulant comes with a price — with thinner blood, the body has trouble patching up any breaks or fissures that open internally. In this case, the patient’s blood made its way to his right bronchial tree, leaving him coughing small clots for days.

To form the record-setting clot, doctors guess that an infection may have caused the patient to produce a higher concentration of a fibrinogen, a protein found in blood plasma that acts as “glue.” Gavitt Woodard, M.D., a clinical fellow at UCSF, figures this protein provided newfound hardiness that kept the clot intact.

“Because it was so large, he was able to generate enough force from an entire right side of his thorax to push this up and out,” Woodard told The Atlantic.

Although the patient ultimately didn’t recover, in that moment, doctors report that he found some relief.

In the meantime, the incident leaves the Internet reflecting how the phrase “cough up a lung,” may be uncomfortably close to real life.

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